Epipen, Generics, and the Challenge to the AAP

Now everyone knows Epipen, the auto-injectable allergic anaphylaxis antidote whose manufacturer is now price-gouging patients who need it. Little Pharma (generic manufacturers, as opposed to Big Pharma, with the blockbuster brand names) has finally, perhaps, gone too far, just as Jose Canseco, Mark McGuire, and Sammy Sosa finally broke the steroid back way back when. A generic company has an old drug that was cheap for years, and instead of simply continuing to charge what it charges and make a normal profit, since it holds a monopoly on manufacturing the drug, it blithely raises the price to the rafters. Those needing the drug have no choice but to pay a lot more than they used to. The biggest difference with McGuire et al., I guess, is that Major League Baseball had the tools to enforce reform. With the federal government prostrated before pharma, the arrow in the quiver is not so apparent. A new arrow will have to be manufactured, because the government can't now price fix in a (fictional) free marketplace for medicines.

I first heard about the generic issue a few years ago when my med school roommate, now an ophthalmologist in Anchorage, told me the price of an ophthalmic generic he uses in the office had gone through the roof. Then there were articles in the media, and pediatricians on our American Academy of Pediatrics SOAPM listserve started complaining that mebendazole, a great and formerly cheap medicine for pinworms, now cost $600. Sneering Martin Shkreli then entered public consciousness by raising the price of daraprim by 6,000% or something, and even Congress had to become aware of the gap in the law. And now Mylan Pharmaceuticals, headed by Heather Bresch, the daughter of conservative West Virginia Democratic Senator Joe Manchen, says she is “just running a business,” but in the process has stepped on the snake of allergic families, who are too numerous to be ignored, by boosting an Epipen two-pack to $600, a supply that has to be renewed every year and a half, and which quite often needs to be paid directly by the patient because of their high-deductible policies. Congress is once again “Shocked! Shocked I tell you, Ricky!”

What a charade. What a charade. You are a professional organization dedicated to the health and well-being of children and their families, but you evade an issue as long as you can, do nothing, have no plan, don't give a crap, really, crocodile tears up to the knees. When the issue finally comes to a head, led by an on line petition from patients, not professionals, patients – they publish a “me, too” statement from our president that commiserates with the financial burden of patients and says not one stinking word about the general subject. No outrage, just hand-wringing.

At the AAP, they tell us don't say “they,” say “we,” “we are the AAP!” OK, I'll say “we.” We are full of crap. We knew it was going on – the listserve had it on there time after time. I suggested to our Committee on Child Health Financing that we compile a list of affected generic drugs and press this on our government. I suggested it publicly on the Listserve. At least confront Congress with the scorecard. Good luck with that.

So the Listserve erupts along with the public over Epipen. One participant points out that the issue was number four in priority in last year's ALF – the Annual Leadership Forum – where the top ten are supposed to be acted upon. Acted upon. That means, taken up as a priority. Something done about it. I said, great, an ALF resolution. Duck and cover, crouch and shelter, because here comes the earthquake of AAP intervention! Right, the Listserve commentator wrote to me privately, it's really a shame what happens to ALF resolutions.

My friend Christoph, Chairman of SOAPM, a courtly and energetic young man from North Carolina whom I like, whom I indeed urged to run for the position, forwarded the issue to another competent and amiable young man (they're all getting young to me, sigh) who heads the AAP Washington office, whom I also like. He responded:

• we have been thoroughly engaged in working with public policy makers, the company and others to address the burdens the high cost places on families and the barriers it creates to accessing this crucial medicine.

• we are working with Congressional staff to help them understand the issues. Since ALF, we have been pursuing an advocacy agenda, led by the AAP Committee on Drugs, and have participated in Congressional hearings as well as HHS meetings on Epi Pen and other drug pricing issues. We have also formally joined an AMA task force on pharmaceutical costs. 

• With AAP support, one of our members ... took our concerns right to the COO and CEO of Milan (sic) earlier this summer.
• To keep up the pressure, Dr. Dreyer is issuing a media statement today.

So I responded:

­Mark, why haven't we heard anything about this?  Why is the President's column in the AAP News always about helping the poor (not that there's anything wrong with that)?  What has the AAP been doing?  Is testimony effective?  What has it been, anyway?  Have I just been inattentive?
There is a whole list of drugs that have gone up and up and up, Schkreli-ized.   What is the AAP perception of the problem?  As someone has said, it's not what's illegal that should be stopped, but what's legal that should be stopped.  What is the AAP preferred solution?  Or at least, where is the AAP explanation of the difficulties of having a solution?
Is the AAP modus operandi to be a soft voice inside the tent, or to make common cause with parents and patients outside the tent?
Is it better for the AAP membership to be left out of the action?  It may be, that's a viable position, but it probably conflicts with the concern for membership numbers.
I have a lot of respect for our Washington people ....  I'm less secure in the AAP's traditional avoidance of public controversy in political matters, and this is a political matter, with lots of money and power on the other side (pharma), some of which spills into AAP coffers, I imagine.  That can lead to an organizational dilemma.

There are lots of questions here.  But at this stage, I think it should be embarrassing for the Academy to be upstaged by an on-line parents' group in a matter that relates directly to the health and well-being of children.

budd shenkin

More discussion followed. Christoph observed that lots went on that we won't know about but that this is appropriate, because the Listserve is available to many people who work for pharma. Some truth in that, but only some. Christoph expressed his confidence in the AAP, which I don't share. But he is congenitally trusting and I'm suspicious, a learned habit.

What kind of an organization are we (“we are the AAP”)? I think we are not a shit-kicking, obstreperous organization, which can be OK. As long as we press forward and stick to achievement. But all organizations need to guard against being a blame organization, where the chief objective of members of the organization is to avoid blame and thereby to keep one's job. There is a difference between patience and complaisance.

Mark's reply is CYA – we have fulfilled our responsibilities to the membership, here are our activities. Our theory? Dunno about that. Our endpoint? A rollback of Epipen prices for a while? That's pretty limited.

In fact, the problem with generics is generic, not particular. What do you do about the phenomenon? It's a puzzle. In a past era of corporate responsibility, corporations did not identify their actions the way the Mylan CEO does, as simply increasing shareholder value. Instead, they saw their responsibilities as extending to the welfare of their clientele, their workers, their community, their country. They identified their actions not in reference to what was legal, but to what was right. Not all of them, and not all of the time. But the feeling was expressed by Charlie Wilson, president of General Motors, when he was asked in his confirmation hearing to be Secretary of Defense in 1953, if he could make decisions as Secretary of Defense that were adverse to the interests of GM, said yes he could, but that he could not conceive of that situation “because for years I thought what was good for the country was good for General Motors and vice versa.” Or think about the relationship of Eastman Kodak to Rochester, New York. So in those days, unlike today, shareholder interest was important, but not decisive.

Not that the 50's were definitive of greatness. The auto industry declined in serving the public well, their organizations became blame organizations, and it took the Japanese for the industry to start serving the public well again, and it's not clear that Detroit ever really caught up. Industries decline – nations decline, for that matter. The point is, for decades the generic industry functioned well. When the patents on brand-named medicines terminated, generics took their place with much lower prices, the public was well served, and the new manufactures made a reasonable profit. Now, like Detroit in the 70s, the generics industry is in moral decline, driven by the nefarious Wall Street perception that the only boundary for industry action should be legality that can't be evaded, and if it can't be evaded, legal change can be bought. Epipen is just a symptom.

Every change in profit-seeking is buttressed by an ex post facto ideology. The current ideology is that of the radical free market, to an extent that Adam Smith never dreamed of. Narrow self-interest has been deified as socially responsible. “Greed is good” prevails. But this is new. In fact, as current debate on the course of capitalism illustrates, there has always been conflict between capitalism and democracy. Democracy sets the playing rules for competition so that it serves the public interest, and democracy also erects such public protections as labor laws, financial regulations, and welfare systems. (see unfortunately behind a pay wall, https://www.foreignaffairs.com/reviews/review-essay/2016-06-13/capitalism-crisis )

And because economics is never stable for long, there need to be constant readjustments. The surprise over the depth of Trump and Sanders support reveals once again how unstable capitalism is, how there are always losers, and how limits always need to be set on the winners. One need not be a Marxist to understand how the triumphs of today lead to the contradictions of tomorrow – how will we pay our populace as robots edge toward the nirvana of less and less boring work? But I digress.

The point is, if custom and moral social responsibility will not regulate a company that finds itself in possession of a monopoly product, how can we restrain the rents obtained? (that is, profit based on monopoly rather than competition and costs.) One way would be to bust up the monopolies by easing entry into the field (reform the FDA), or even subsidizing the creation of competitive entities. This would be nice, but oligopoly is not a great solution to monopoly, much as we welcome the self-regulating mechanism of competition. Oligopolists also enjoy rents. Another would be to regulate profits of the generic industry – difficult, but it could be done by clever economists. I could imagine other solutions as well, but whatever, it is crystal clear that something needs to be done.

How does this relate to the AAP? For government to act, there needs to be public pressure. As FDR said when meeting with a convincing case presented in his office (paraphrase): “You've convinced me. Now you need to go out there and make me do it.”

If you want to keep your job, you can follow procedures. You can refer an issue to the Committee on Drugs (what did they do, I wonder?). You can “meet with Congressional staff,” which means bring the issue up when you are meeting with them anyway. Etc. You can “maintain your relationships” with your counterparts in government. You can defend yourself before your constituents by citing procedures followed.

Or you can make the case and build up pressure. The NRA has no problem doing that. They educate their members on the issues at hand, they meet forcefully with representatives in Congress, they threaten vengeance on non-adherents. They aren't lovable – Wayne La Pierre is probably psychotic – but they sure are effective.

The AAP (I forgot - “We”) could make the case to our membership. What pediatrician is not enraged by these price increases, but these suddenly unavailable medicines? Instead of sending out email missives “let your Representative know!” “we” could really organize and bring it to them. We could get our task force moving in important districts. We could have a position, for God's sake – currently all we have is hand-wringing. We could have a newsletter that mentions the issue now and then, and actually elucidates the general problem so that there really is a general consciousness and understanding within the organization members.

“We” could generate a sense of outrage. Here are companies that act against the general welfare under the guise of “doing business,” as thought that were clearcut. “We” could push as though we meant it. “We” could actually stand for something against the weight of pharma. Think it's dangerous to do so? David probably did also, thousands of years ago, but he seems to have done pretty well.

Google says, “Don't be evil.” The AAP could say, “Don't be pusillanimous.” In both cases, it's naming the temptation to be avoided.

Or maybe I'm all wrong. Who knows? Maybe the spontaneous patient uprising was covertly ignited by an AAP agent. Wouldn't that be a great surprise?

Budd Shenkin

ACA Loses Players in South, Rural Areas

The current headline is that the ACA is losing insurance players in the South and in rural areas: http://www.nytimes.com/2016/08/20/upshot/obamacare-options-in-many-parts-of-country-only-one-insurer-will-remain.html?utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_source=hs_email&utm_medium=email&utm_content=33221403&_hsenc=p2ANqtz--irR_Eb4J3TRTb_Sqw8o7k8-395GjpFwyrOV99xXN0TWS26sL7B1yyTTEBdA3BRcLRs9RdpHDYOxCgrcq5TCDcjcRpDQ&_hsmi=33221403&_r=0

We've all read about United and now Aetna withdrawing fully or mostly from the ACA plans.  Many variables explain this, among them the Obama decision to let some patients stay in their current plans and thus not populating the Exchange plans, plus the basic idea that the young and well would pay for the older and sicker, and also the fact that so many newly insured were too sick to be insured previously.

But lurking behind that, I think, is that the insurers have not found a good way to lower costs - although the cost increase is at a lower rate than before the ACA - and the fact that the ACA didn't provide many tools for lowering costs, as we all knew at the time.  They opted for increased coverage, a worthy goal, but insufficient in the long run.

In looking for doctors and hospitals to join their cheaper plans, the insurance companies simply asked them to take less payment, which many have refused to do, since their other books of business were large enough that they could survive without having to take in this lower paying contingent. So the result is, decreasing choice.

Hillary Clinton's resurrecting the idea of a public option, and/or Medicare for decreasing age levels (age 60, age 55) may be a stop gap, but what is really necessary is a way for costs to decrease where they are most egregiously high.  Medicare has done its part at times -- when we used to eat lunch at the doctors' table in the hospital, we'd hear the ophthalmologists' complaints that they could no longer get $2,500 per cataract, poor babies.  Then the cardiologists complained.  I would turn to my pediatric colleagues and say, "Let's commiserate with them when they get down to our level," which of course never happened.

Now Medicare is totally revamping the way they pay, targeting fee-for-service as the culprit, and substituting risk-based payments, or value-based payments. Maybe some of it will work, but probably not very well. I concur with Jonathan Oberlander's cautious attitude: http://www.nejm.org/doi/full/10.1056/NEJMp1509154#t=article

The problem is Medicare's size and consequent remove from the details of care. Yes, size gives power, just ask the ophthalmologists and cardiologists. But the larger the size the broader the strokes. The value-based payment program takes the economists' ploy one step further. The economists say, “Imagine if we had a tool that could discriminate value....” Medicare and other payers say, “We have a tool that can discriminate value.” But where is that tool? It's not obvious that they have it, sorry to say. Yes, they can determine truthfully that a certain back surgery is overused and often useless or worse, but their only response to this knowledge is to refuse to ever pay for it, thus depriving those patients who really could use that surgery from coverage that justice should afford them. And that's just one example; there are literally thousands upon thousands. And incentivizing “quality” by the by-now ancient and increasingly discredited P4P (meet certain requirements for routine quality of care) is not likely to do the trick. Increasing the distance between provider effort (actually seeing the patient) and payment is not guaranteed to make medicine smarter and more efficient.  As Donald Trump would say, "Believe me -- not guaranteed.  Believe me.)

What we really need is a marriage of Medicare's power and the knowledgeable discrimination of more decentralized organizational units. That could be local IPA organizations of doctors; that could be specialty organizations, both of which could pay more attention to nuance. There could be public spirited hospital based entities that ruthlessly dissect the monopolistic, profit-protecting hospital industry to deploy proper conditions for competition, and proper regulation of hospital practices. Ojala!

The problem with this scenario, however, is as always, money and power. Regulatory agencies are subject to industry capture. Today's Medicare Administrator is tomorrow's President and CEO of America's Health Insurance Plans, succeeded by a former official of Optum, a division of United Health Care – and that's in a Democratic administration (centrist, it's true, but still....)

Should hospitals be “the center of the system,” as they and many health policy theorists have long proclaimed? Although there are many of us who think this is a poor proposition, that's the original thesis behind the creation of Accountable Care Organizations, created by the ACA as a new organizational entity that will streamline care and reduce costs. Right, with the hospitals in charge. Yes, there are some primary care based ACOs, and they have generally proved better than the hospital-based ACOs, but try getting that to be national policy, when the current money and power is in hospitals and large medical centers. Just try to.

To recount this argument: Medicare has the power, but they need more decentralization to deploy it properly, and the agencies that pop up to be those centers of decentralization are, mirabile dictu, inevitably those with the most to lose and the most to protect. It's a challenge.

Nonetheless, we must be hopeful. Hopefulness is a moral necessity. Experience shows that setting goals is often over-ambitious, but that estimates of our own capacity are often overly pessimistic. The challenges are greater than we think, but our power to act is also greater than we think. So, I am hopeful, and always will be.

It turns out that, despite my decades long history as a practical practitioner of the art of medical organization, I am at heart an ideas man. I believe that if one can articulate the problem and the solutions properly, in the end, ideas will supply the fodder for enlightened action in a properly functioning democracy – we are not properly functioning, but we are probably good enough over time, I think. And there is never just one solution, there are simply steps taken one by one toward possible solutions. To requote Keynes: “Practical men who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist. Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back.”  I would just substitute "policy analyst" for "economist."

So, in the short run, some areas of the country will be faced with fewer insurance choices and probably quite narrow networks of providers. In the medium run, we will have multiple levels of care. Some of the levels will have more conveniences than others; some of the levels might actually have a lower quality of care. But I would doubt that we will get to the point where wealthier people can get a lifesaving drug and less fortunate people cannot. I doubt that specialty operations and medical treatment will be denied the less fortunate. I think the ACA will always be seen as a positive step toward more equity of care, and over time the levels will converge, although never completely.

In the meanwhile, I don't see any substitute for continuing effort and vigilance by well-intentioned people – generally described as those who agree with me – in examining conditions and proposing improvements. The great virtue of the ACA was breaking the logjam that was health care policy. Now that we see the logs flowing down the river, bumping into each other and crashing into the river banks, it is our job to prod them into a coherent whole that promises stiller water and streamlined flow ahead.

As we say, “Ojala!”

Budd Shenkin

How Marcus Welby Can We Be?

I was already a doctor when Marcus Welby, M.D., came onto TV screens.  It wasn't something I would watch. I was busy, it was network TV, it was sappy, it was suburban WASPy Republican without the Beav's charm, and he was a general practitioner (who amazingly seemed to have one patient a week). Even though my grandfather had been a general practitioner before he died of a brain abscess in 1933, my Dad was a neurosurgeon, so in our family specialty trumped general practice. My Dad's distrust of other doctors, like GP's, was such that he said each generation of a family needed at least one doctor, to protect them from the shit that is out there. So for his generation, he was it.

(Many will remember neurosurgeon Ben Casey, which was nearer and dearer to my father's heart.  He enjoyed the lionizing of his specialty, his face lighting up with reflected glory. I think he watched it. I didn't; I was busy in college and med school and didn't have a TV.)

So, my Dad organized our care, either dispensing it himself, or choosing the doctors personally and carefully. When I broke my leg sliding home on an ill-conceived steal attempt, he took me to the hospital and his friend Chuck Kambe operated. When my Mom needed back surgery (twice), my Dad did it personally, saying there was no reason his patients should get better care than his wife. If we were sick he might call in his GP friend Dave Cohen to help, after Dad checked our Babinski reflex to make sure we were neurologically intact (first things first), and Dave gave us our shots, but Dad never really gave up the reins. When I went to a Harvard recommended dermatologist for a skin lesion that wouldn't heal and the dermatologist failed to help me, Dad sat me down with the Medical Letter and we treated it successfully with griseofulvin. I went with him once on a consultation to a community hospital ER, and I said afterwards, didn't the patient really need a neurologist rather than a neurosurgeon? My Dad growled his answer: “What that patient needed was a smart doctor.” QED.

Then I became a pediatrician. Not easily. When my Dad told his colleagues at the hospital lunch table that I had decided to go into pediatrics, they said, “Henry! Those guys work their tails off and they don't make any money! ...Can you talk to him?” They knew where their bread was buttered, for sure.

It took me a long time to become a good pediatrician. I had graduated from a specialty program that had little primary care – actually, nearly all residencies are specialty programs, and the outpatient clinics are models of poor organization – so I didn't know much about practicing, but some of what my Dad taught me probably stuck. I didn't realize it at the time, but my learning to practice took me, inevitably, to the importance of caring for each individual person. I found out that what people wanted was, predictably, Marcus Welby.

They wanted someone who cared for them (preferably only them), someone who was competent, caring, and reliable. And accessible, very accessible. The caring came naturally to me. The rest I had to work on. Thankfully, I had a gift for organization, so the practice became a success.

Marcus Welby functioned well, however, only in the idealized atmosphere of TV and the time when we had so many fewer tools, and so many fewer specialists than we have today. He saw some patients in the hospital, called a specialist at times and dropped into Xray to read the films, I guess, and I think I remember that he showed up at odd times at the family's house. My Dad would approve of that – he said that trust in doctors eroded as soon as doctors no longer shared a cup of coffee at the patient's kitchen table.

Well, those days have been put to rest by the plethora of tests and treatments and specialty care. Modern medicine can do so much more for patients than old-fashioned medicine, that a single doctor can't keep it all in his or her head. There is too much to do to be tooling around town, showing up and kibbitzing. Patients might still want Marcus, and doctors might still want to be his disciples, but to meet these expectations, care has to be organized in a new way.

The question is, how do you do it? How do you organize your practice so that you get Welby-like results in the modern environment, trust and intimacy linked to modern science?

I have to hand it to my fellow pediatricians. I've talked about our American Academy of Pediatrics listserve for the Section on Administration and Practice Management (SOAPM). If my Dad could have seen what goes on on the listserve, how my primary care pediatrician colleagues struggle to do the best possible, to think everything through, he would have been gratified and amazed. So, to illustrate the point I'm making, here are two recent exchanges 0n the listserve about how we are facing the dilemmas of practice.

First, Kerry Fierstein of Long Island:

“This weekend, I had one dad call at 10 PM Saturday night needing a camp form filled out before 9AM when they were driving to soccer camp, and at 12:30 AM another dad called for a Lialda Rx because teenage son with UC ran out and they were leaving on a cruise at 7 AM and GI didn't have an emergency number.” These are extreme patient demands, but Kerry accommodated them! Amazing, to me. Part of her thinking apparently was that, as a Patient Centered Medical Home, her practice needs to honor patient needs as much as possible. More on the PCMH below.

Second, from Ashraf Affan of Jacksonville: “Can any one recommend a good pediatric call center that can handle calls during the day to schedule visits, etc, for a fairly large private practice. We are trying to weigh outsourcing the job vs. housing in.” He received many answers from the group, most replying that you have to do it yourself in your practice.

Michael Sachs of Los Angeles told of his experience: "We're about to (reluctantly) go to an auto-attendant and voicemail during office hours for the first time ever. It was either that or hire more people to answer incoming calls, but we don't have the physical space and would prefer not to pay one or two additional salaries. … We're not big enough to use a scheduling center or outsource, but having been on the patient end of scheduling a visit for one of my kids at a local major medical center, it was a time consuming PITA. First talk to an intake person and be told that a nurse would look over the information. Then receive a phone call back a day or two later with the great news that a nurse has approved the visit.....and the same scheduling person I'd spoken to the first time now wanting to know when I'd like the appointment. 'OK, I'll see if that's available and will call you back' Couple of days later, a call back with more great news - that time is available! Now the appointment is scheduled. A few days before the appointment, the same person calls back again to confirm the appointment time. But he doesn't have the appointment time, he asks me when I show the appointment is scheduled. Tell him, he puts me on hold for a few minutes, then returns and confirms that it's the same day and time he shows in his system. Now I'm getting a bit concerned since it seemed that he didn't know WTF he was doing so I called directly, spoke to a receptionist in the physical office, and she confirmed that the day and time were correct. Whew, that was a relief. Total time scheduling and confirming the appointment: at least 30 minutes.”

Suzanne Berman of Crossville, Tennessee offered another alternative: “We have a 'call center' model (although our call center is physically located in our office) staffed with 4 nurses and 1 one receptionist/non-nurse. Going to this model cost us a lot in the beginning, because nurses make 30-40% more/hour than receptionists (on average, YMMV). BUT we found that the nurses could do triage AND scheduling ('yes, that belly pain needs to come right in; no, your bug bite is not a 5:30 PM emergency'). They could also more holistically look at the whole chart and the whole family. Like, they're making an appointment for sib A and they say, 'Hey, I notice Sib B needs a checkup. Are you bringing him with you? OK - wanna do his checkup?"'

This improved our recall/compliance an awful lot. In short, we found it was more cost effective to have nurses evaluate the possibility of 'super-sizing' the visit on the front end (when the patient was pretty much already committed to coming into the office anyway) than using lesser-paid receptionists trying to do recalls post hoc on overdue patients. (I mean, we DO do recalls too, but it's a lot easier to get them in in the first model.)”

First, Kerry's situation and her heroic efforts to accommodate her patients. I think you can look at this as a spectrum of how we balance patient convenience with doctor convenience. Way on the left side of the spectrum is the old model clinic where my father used to work at Philadelphia General Hospital a half-day a week, where care was free and the doctors unpaid, when it was an honor to be chosen to work there, and where appointments were probably given at 8 AM for every patient who was to be seen that morning. The care would be excellent, but the amenities not so much.

Way on the right side is Marcus Welby when that was feasible, and in the present day, almost to the end of the right side of the spectrum (but not quite), is the Patient Centered Medical Home (PCMH). A PCMH centralizes all care for the patient, keeps all records, not only makes referrals but helps the patient make the appointments and follows up by telephone to make sure the referral was completed, teaches patients how to care for themselves, etc. To do this, the PCMH employs non-physicians to help and practices what we call team care. It's the center for the patient, it's the place they get treated like they are at home.

Even farther to the right, however, way out there for the modern equivalent of Welby-care, is concierge care. In this model a practice cuts way down on the number of patients it serves. Given the extra time thus available, the concierge practice does all the PCMH does, and in addition offers exquisite availability of the same doctor nearly every time on the same day you call, extended time for consultations, extended counseling and coordination services, and great concessions to patient convenience, like call to the doctor personally 24/7. I've probably left out other important services. Examples of concierge care that would not be expected in a PCMH would be: meeting the patient in a parking lot or on a sports field for patient convenience; sending a patient to two or three different allergists for consultations, speaking personally to each of them, and then meeting with the family to come up with an allergic plan; giving the patients a traveling kit of common medicines, including antibiotics, so they don't have to go to a pharmacy. This is Welby-plus care in the modern age.

Of course, PCMH and concierge care cost more. In addition to the normal fee-for-service payments, PCMH care requires a yearly fee, and/or per-patient-per-month capitation fees, or fee-for-service payments at a higher level. Concierge care requires even higher, paid in advance fees – sometimes, the payment is unbelievably high, from what I've heard. In contrast to the PCMH model, the concierge model actually decreases staff overhead, since fewer patients are served and the operation is thus simpler. It's an interesting model, although clearly not for every doctor, and not for every patient. Office automation lies behind both models – you can't do all this on paper. Automation actually enables decentralization, and in these cases, enables more Welby-like care with modern medicine modalities.

So, the dilemma is faced: how do you operate like Marcus Welby in a modern context, and these are the answers. It takes work, but in the end it looks to be very possible. It costs more, but since most medical costs center on the hospital, the extra cost for high intensity primary care is probably budget dust.

Second, Ashraf, Mike, and Suzanne's case of how to handle the phones. Once again, I would apply the “poverty clinic to the left, concierge to the right” spectrum. Clearly, at least to me, the medium is the message. Phone tree or outsourced call center, and you are moving left, where doctor convenience trumps patient comfort. Talk to a person, have that person kind and focused on you and taking time with you, and you are moving right toward Marcus. But note Mike Sach's experience in making an appointment himself with a hospital-based practice – it's a corporation! Corporations – and hospitals are very much corporations -- feel they have to centralize, they have to be impersonal, they have to impose their will on you for their own good and their own convenience. The doctors can be fine, once you get in, but with corporations in charge, the feeling often gets to be that it is you the patient along with the doctor fighting corporate practices and policies! So far, they just don't know any better.

So, here it is in some of its details, the modern dilemma of organizing primary care. Will it go corporate? The thumb on the scales is in favor of the corporations, who get more money per patient by their superior insurance contracts. Or will the smaller, more personal, more Welby-like practices, empowered by personalizing automation, survive and prosper? Or will the corporations change their spots and learn to incorporate personal care in a personal way? (The keys here will be, I think, one, how competition can be organized to work in favor of patients' needs and desires, and the needs and better-angels desires of doctors, and how doctors can muster the skills of leadership and organizational change – but more of that later.)

Modern medicine is great; we can do so much more than my Dad's generation, and each year is better than the year before. But even if we can't share a cup of coffee at the kitchen table, and even if we can't pop up at the patient's house at odd hours, we can preserve the personal relationship that is the key to medical practice, as I learned, and be competent, caring, and reliable – and non-bureaucratic. It's just a question of organization, and of competition that spurs better organization and better, more personal care.

Budd Shenkin